Provider Demographics
NPI:1811946965
Name:PETERY, JOHN ANDREW (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:PETERY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5921 W FRIENDLY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-3268
Mailing Address - Country:US
Mailing Address - Phone:336-218-8490
Mailing Address - Fax:336-299-6533
Practice Address - Street 1:5921 W FRIENDLY AVE STE D
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-3268
Practice Address - Country:US
Practice Address - Phone:336-218-8490
Practice Address - Fax:336-299-6533
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC409213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU22761OtherUPIN
NC690193TMedicaid
NC890801UMedicaid
NC10387801OtherCAQH
NC690193JMedicaid
NCP00791221Medicare PIN